Provider Demographics
NPI:1013134717
Name:MARVIGLIA, MELISSA CHARLOTTE (DPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CHARLOTTE
Last Name:MARVIGLIA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4771 E MEADOW LARK WAY
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85240-5207
Mailing Address - Country:US
Mailing Address - Phone:480-830-2445
Mailing Address - Fax:480-677-8921
Practice Address - Street 1:3341 E QUEEN CREEK RD
Practice Address - Street 2:SUITE 109
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-8501
Practice Address - Country:US
Practice Address - Phone:480-621-8361
Practice Address - Fax:480-621-8513
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ58992251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ722729Medicaid